Amenorrhea

Definition

Amenorrhea literally means absence of menstruation.

It is symptom and not a disease. Overall prevalence of pathologic amenorrhea is about 3-4 %.

PRIMARY AMENORRHEA

Definition

A young girl who hs not yet menstruated by her 16 years of age is having primary amenorrhea rather than delayed menarche.

Cause

Cause of primary amenorrhea are grouped as follows:

1- Hypergonadotropic hypogonadism

• Primary ovarian failure

• Resistant ovarian syndrome

• Galactosemia

• Enzyme deficiency

2- Developmental defect of genital tract

• Mullerian agenesis or dysgenesis

• Imperforate hymen

• Transverse vaginal septum

• Atresia upper third of vagina and cervix

• Complete absence of vagina

• Absence of uterus in MRKH syndrome

3- Hypogonadotropic hypogonadism

• Delayed puberty

• Hypothalamic and pituitary dysfunction

• Kallmann’s syndrome

• CNS tumors

4- Abnormal chromosomal pattern

• Turner’s syndrome

• Various mosaic states

• Pure gonadal dysgenesis

• Androgen insensitivity syndrome

5- Dysfunction of thyroid and adrenal cortex

6- Metabolic disorder

7- Systematic illness

Diagnosis

Physical appearance

• poor breast development

• scanty pubic hair

• status – short

• webbing of the neck

• mental retardation

• obesity External genitalia

• underdeveloped

• labial fusion

• enlargement of clitoris Internal genitalia

• absence of vagina

• absence of uterus

• underdeveloped

• short blind vagina

Investigations

° USG

° MRI

° Laproscopy

° HSG

° Progesterone challenge test

° Serum gonadotropins

° Serum estradiol

° Gonadal biopsy

Management

The scope of the therapeutic success in the management of primary amenorrhea is very limited.

Developmental Anomalies:

The principal of vaginal reconstruction is to create an avascular space between the bladder and rectum.

Chromosomal Abnormalities:

Short term use of combination of estrogen and progesterone is indicated at least for development of breast.

Hypothalmo-pitiuitary-ovarian Axis Defect:

Puberty may be induced using oral estrogen and progestin therapy when there is severe delay.

Thyroid and Adrenal Dysfunction:

Gross thyroid hypoplasia does not respond to thyroid replacement therapy.

Mild hypothyroidism may have good result with replacement therapy.

SECONDARY AMENORRHEA

Definition

It is the absence of menstruation for 6 months or more in a women in whom normal menstruation has been established.

Cause

1- Uterine factors

• Tubercular endometritis

• Post radiation

• Surgical removal

2- Ovarian factors

• PCOS

• Premature ovarian failure

• Chemotherapy

3- Hyperstrogenic

4- Androgen excess

5- Hypostrogenic state

6- Pituitary factors

7- Hypothalamic factors

8- Adrenal factors

9- Thyroid factors

10- General disease

• Malnutrition

• TB

• Diabetes

• Chronic nephritis

11- Itarogenic

• Contraceptive pills

• Psychotropic drugs

• Antihypertensive drugs

Investigations

° Estimation

° CT/ MRI

° Progesterone challenge test

Management

1- Hyperprolactinemia, Inappropriate Galactorrhea:

Bromocriptine→dopamine agonist Cabergoline→long acting dopamine agonist

2- Premature ovarian failure: in proved cases of autoimmune disorder corticosteroids may be of help.

3- Hypothyroid state: thyroxin

4- Hyperandrogen state: using oral contraceptives, glucocorticoid or antiandrogen.

5- Ovarian tumor: appropriate surgery is done.